Maternal and newborn mortality rates remain alarmingly high in Pakistan. At the same time, access to contraceptives and reproductive health services is limited, leading to a high fertility rate (3.6 births per woman) and a population that has more than tripled over the last 50 years, straining the country’s limited resources.
To improve access to family planning and sexual and reproductive health services, the Aga Khan Foundation and the United Nations Population Fund launched the Sehatmand Khandan (Healthy Family) project in 10 districts of Gilgit-Baltistan, Khyber Pakhtunkhwa and Sindh with poor reproductive health indicators. To assess the state of the affairs in the districts and the project’s impact, researchers led by Professor Tazeen Saeed Ali from AKU’s School of Nursing and Midwifery conducted a total of more than 150 group discussions and nearly 180 in-depth interviews with individuals before and after implementation.
Conducted between 2020 and 2023, the project consisted of a wide range of interventions. Workshops were held to help health care workers deliver better and more sensitive sexual and reproductive health services. Adolescent-friendly centres were established to provide access to information about reproductive health, family planning and gender-based violence. A voucher programme was implemented to pay for transportation and emergency expenses for families seeking reproductive care. Access to care in remote areas was increased through telehealth services and mobile apps, and health facility infrastructure was upgraded.
In addition, after her baseline study revealed that gender-based violence (GBV) was a widespread but underreported problem, Professor Ali and her colleagues added a gender-based violence component to the project. They led workshops for stakeholders (commissioners, police, teachers, religious leaders, journalists, etc.), mapped locations where GBV-related services are delivered, developed referral directories for eight districts in Gilgit-Baltistan and Khyber Pakhtunkhwa, and conducted high-level advocacy for institutionalizing gender-based violence screening and care.
Professor Ali’s interviews revealed that the overall Sehatmand Khandan project had a number of positive outcomes. These included improved accessibility and utilization of services, enhanced awareness and demand for contraceptives and GBV services and cultural shifts among adolescents and women. At the same time, interviewees cited a number of ongoing challenges, including the limited number of facilities and providers in the districts, difficulties affording family planning services, misconceptions regarding contraceptives and cultural norms that disempower women.
The following quotations from participants provide a sense of the contexts in which the Sehatmand Khandan project was undertaken and its impact.
A woman in Astore: “Contraceptives are not given to us for free, so a poor person cannot afford birth control.”
A Lady Health Worker in Matiari: “We haven’t had condoms for two years. We have a limited supply of injections and pills.”
A woman in Astore: “Religiously, it is only permissible to control birth for two years. We can’t use a permanent solution to control birth.”
A woman in Nagar: “Men don’t like the use of contraceptives. It causes fights.”
A woman in Ghizer: “The [vouchers] helped us with transport. This assistance was crucial as it ensured timely access to medical care during my pregnancy. It saved both my child's and my life.”
An adolescent girl in Nagar: “Early marriages are very common here. My mother herself was married at the age of 14 and now she has 11 children. My sister was married at the age of 18 years.”
A woman in Matiari: “Local women claim that using an IUCD [Intrauterine Contraceptive Device] harms women's health and makes them weak.”
A woman in Hunza: “We have a problem with the transport system. The health center is not here. It is in another village. The distance is too great.”
An older adolescent in Gilgit, speaking about younger girls: “When I was their age, no one guided me about [menstruation], so I got really scared and started crying because I thought something went wrong. But now, because of AFC [the adolescent-friendly centres], they are much more aware.”
A health official in Matiari: “There was a 16-year-old girl who received a marriage proposal from her uncle's son. She took a stand and said that she wouldn't get married until she turned 18. This decision was influenced by the sessions we conducted. She explained it properly, not inappropriately, and emphasized what would be better for her health. Everyone agreed with her decision.”
A Lady Health Visitor in Astore: “Now women come and ask for [contraceptive] implants. They are really glad that they can avoid pregnancies.”
The Sehatmand Khandan study addresses Sustainable Development Goals 3 and 5, including their targets related to sexual and reproductive health.